CHEMICAL SUICIDE BRIEFING Drew Fried, EMT-CC Certified Healthcare Emergency Professional Special Thanks to the NASSAU COUNTY FIRE COMMISSION HAZARDOUS MATERIALS COMMITTEE Unresponsive Person in a Vehicle Photo Sources: St. Lucie County (FL) When a citizen calls 911 to request medical assistance for a person that is unconscious or sleeping inside of a vehicle, it is important to ask questions about the scene to determine if the incident is a possible chemical suicide. It is critical that the caller and citizens stay clear from the vehicle. 1
Emerging Threat There have been several documented cases in the United States of the use of readily available household chemicals as a method to commit suicide that can expose responders to a significant health and safety risk. The method involved mixing two readily available, household chemicals to produce a flammable, toxic gas. The resulting gas causes the victims to go unconscious and suffer heart failure. Statistics Suicide by hydrogen sulfide exposure is a very popular method overseas Originated in Japan 2000 cases since 2007 Plagued the U.S. since 2008 Info readily available on the Internet 2008 3 incidents 2009 9 incidents 2010 >30 incidents Cases believed to be drastically underreported in U.S. Scenario: It s Sunday at 0630 hours, your agency responds to an unconscious person in a vehicle. You locate the car in the empty lot of a business. You approach the vehicle and see a male inside that appears to be unconscious. Wearing initial medical PPE (exam gloves), you find the doors locked and knock on the window. Receiving no response it s decided that you will force entry by breaking a window. Once this occurs a rush of warm air comes out of the vehicle and you smell a sharp odor. 2
Chemical Suicides Emerging Trend Pasadena, California: H₂S -23 y.o. male in a car w/signs Pennsbury, Pennsylvania: H₂S -male on a remote road w/sign Bloomington, Indiana: H₂S student in the closet of a sealed & barricaded room w/sign on door. Police smelling a chemical odor in the hallway evacuated hundreds of students for hours. Cayuga, California: H₂S -22 y.o. male in a car w/signs Sugar Creek, Missouri: HCN -male in a car 4 FF to hospital Kingston Township, Texas an MVA into a tree as a result of a successful suicide while driving w/o signs victim had mixed the chemicals while driving collision left a mustardcolored splash on the interior window Calumet City, Illinois: H₂S-40 y.o. apartment Jan 2011 Close-call? PD enters despite indicators & signs Calumet City, Illinois: Helium gas with an exit hood in a vehicle June 2011 w/o signs Tinley Park, Illinois: CO produce by charcoal briquettes in a sealed room September 2011 w/o signs Hydrogen Sulfide Gas Colorless gas strong odor of rotten eggs or sulfur Commonly known as Sewer Gas Extremely toxic by inhalation Large risk to first responders without SCBA As little as one breath can cause death in 40-50 seconds Chemical formula is H 2 S IDLH = concentration of 100 ppm. Highly flammable with a wide flammable range of 4% - 44% 3
Hydrogen Sulfide Gas H 2 S is heavier than air (VD 1.19) Vapors may be knocked down with water vapor Runoff is toxic and corrosive Acute exposure may require victim decontamination Remove clothing Double bag clothing and belongings A diagnostic clue to extreme H 2 S exposure is the discoloration of copper coins in the location of the victim (turn black) The Process Involves mixing of a sulfur based material (most commonly Bonide ) with hydrochloric acid (Muriatic Acid). Both easily obtainable. Results in chemical reaction that releases large quantities of hydrogen sulfide gas (H 2 S ) ½ cup (120mL) of each product will produce 1000ppm inside a vehicle cabin or confined space (3500 cubic feet) Victim quickly rendered unconscious and will subsequently succumb to the exposure Physiological Effects Rapidly interrupts aerobic metabolism at the cellular level. Results in rapid unconsciousness and respiratory arrest Prognosis of a sufficient exposure is poor At low doses H 2 S results in profound CNS effects and altered LOC As the dose increases, patient will rapidly lapse into unconsciousness, respiratory arrest, seizures, coma and death 4
Symptoms associated with hydrogen sulfide exposure include, but are not limited to: Tachycardia: abnormally rapid beating of the heart, usually over 100 beats per minute Bradycardia: slowness of the heartbeat, usually under 60 beats per minute Dyspnea: difficult, labored breathing Tachypnea: excessively rapid respiration Cyanosis: blueness or lividness of the skin, as from imperfectly oxygenated blood Delirium: a state of violent excitement or emotion Photophobia: abnormal sensitivity or intolerance of light Chemical Conjunctivitis: inflammation of the conjunctiva (mucous membrane that covers the exposed portion of the eyeball and the under surface of the eyelid) caused by exposure to chemicals. Headache Throat Irritation Taste of garlic in the mouth Physiological Effects Cyanide Antidote Kit The effects of H 2 S are the same as cyanide poisoning Treatment is similar if antidotes are RAPIDLY available Amyl nitrate and sodium nitrate Response to Chemical Suicides Awareness These situations commonly occur in: Vehicles Residential bathrooms/dorm rooms Other small spaces where a small amount of gas can quickly reach lethal concentrations Dispatchers and call takers should warn callers not to approach, or enter vehicles, rooms or apartments where unresponsive people may have committed chemical suicide 5
Response to Chemical Suicides Air sampling equipment can be used to determine the presence, or absence of hydrogen sulfide or hydrogen cyanide A small hole may be punched in a car or home window, or a probe, or cholormetric tube inserted in the gap between a door to the room and the floor A hydrocyanic acid tube will detect hydrogen cyanide. Warning Signs Apparent unconscious patient located in a locked car or a small enclosed area Presence of a large container (e.g. 5 gallon bucket) Pungent odor (rotten eggs) Not a reliable indicator due to olfactory paralysis Smaller containers (i.e. acid bottles, sulfur compounds) Warning Signs 6
Responder Safety First responders can be the first exposed to this hazard. Typically, persons committing this act have left hazardous warning signs displayed to anyone approaching the scene. This is not always the case. v1 Warning Signs Some internet outlets encourage posting signs on doors & windows warning responders DON T RELY ON IT BEING THERE Warnings/Indicators: Vehicle Suicide note visible or posted. One or more posted warning signs. Buckets, pails, pots or coolers in the vehicle containing a variety of chemicals. Empty containers of chemicals in or around the vehicle. Smell of rotten eggs or unusual odors. v1 7
Warnings/Indicators for Structures Any exterior visual signs as you approach the residence or apartment. Warning Signs posted on the front of the house or apartment. Doors may taped or sealed from the inside. Other persons from inside the location complaining of difficulty breathing. The smell of rotten eggs or other unusual odors in the area that gets stronger as you approach the location. Be prepared to evacuate the residence or apartment building. v1 Dispatch Considerations Dispatchers and call takers should warn callers not to approach, or enter, vehicles, or rooms where unresponsive people may have attempted chemical suicide. The caller may say there are warning signs on the vehicle or location but may not volunteer this information. v1 Dispatch Considerations Warning signs may be removed, become detached or dislodged, or blow away before responders arrive on scene. The caller may not say anything about a strange or unusual smells unless prompted when they call 911. Proper initial questioning may yield information vital to the safety of the first responders. The information must be immediately passed on to the first responders by the 911 personnel. v1 8
First On-Scene A chemical assisted suicide becomes an emergency response and a crime scene at the time it is discovered. The Public Safety Official who discovers a chemical assisted suicide is considered the first on-scene This incident is to be considered a CRIME SCENE and should be treated as such! v1 Treatment If victim deemed a potential patient, initial treatment would be supportive in nature Double bag clothing and belongings Decontaminate with copious amounts of water if the patient has been directly contaminated by the acid or sulfur A, B, C s Antidotes if available Treatment Rapid assessment and initial medical practices are a necessity High dose oxygen concentration shall be delivered to the patient as soon as practical. (This may be started during decontamination) The medical technician in charge shall notify Medical Control to contact the appropriate hospital as soon as practical and advise of the type of exposure and the number of patients involved 9
IMPORTANT Never transport a contaminated patient!! Remember, leave the contamination at the scene of the emergency, and NEVER take it with you to the hospital!! EMS Scene Ops Field Decon Clothing should be removed and double-bagged. Contaminated clothing and PPE should be laundered before being re used. If alive, the victim should be immediately stripped and decontaminated with soap and water before being transported from the scene. v1 Field Decon Responders must initially utilize emergency decon for rescue operations. Deceased victims should be covered by a sheet and may require decontamination. v1 10
Transportation Use of Body Bag is recommended if patient occupies same space as driver Pre-Planning should occur with ME, hospitals & transporting agencies on utilizing open vehicles such as official pickup truck Recontact Medical Control (on Med Channel assigned) Update on treatment provided and any other info received from Poison Control Obtain specific instructions regarding entering the hospital Protect patient compartment from contaminants Air transport is inappropriate for contaminated patients Arriving at Hospital Await direction from hospital personnel before entering hospital Assist hospital personnel with patient decontamination and treatment as requested Arrange for personal decontamination Mineola Incident Saturday May 28, 2011 Pt. Off-Gassed in Winthrop ED ED Closed 5:15 PM to 9 PM Pt. Survived Attempt 11
Other Suicide Methods Cyanide sodium cyanide & hydrogen cyanide Bitter almond smell Level A Suit Flammable Inert Gasses nitrogen, helium Toxins carbon monoxide Seaford Incident Thursday July 28, 2011 Helium Fremont woman found dead in car in apparent suicide using hazardous chemicals A woman died in an apparent suicide in the Central/Downtown neighborhood early Wednesday morning in a car that contained a poisonous substance -- a suicide method that first gained notoriety overseas four years ago, 12
11-16-2011 The Southampton Hospital Emergency Department entrance was shut down for several hours early Wednesday morning as hazardous materials crews responded when a man attempted to commit suicide by mixing dangerous chemicals in his car, parked at the ER entrance, to create deadly fumes The chemicals appear to have been sulfuric acid and muriatic acid the latter a chemical used to clean bricks and Gunite 13
Hydrogen Cyanide Colorless gas, or bluish-white liquid with smell of bitter or burnt almonds Chemical formula is HCN Extremely toxic by inhalation and/or skin contact Concentrations as low as 270 ppm can cause death in 6-8 minutes Made by mixing cyanide containing compounds with acids Hydrogen Cyanide HCN is lighter than air (VD 0.94) Vapors can be knocked down with water vapor Runoff should be contained if possible High concentrations (>270ppm) can cause LOC/death Exposure to HCN will require victim decontamination Remove clothing, shower with water 3-5 minutes Double bag clothing and belongings USE OF BODY BAGS IS RECOMMENDED FOR TRANSPORT ONLY Seek guidance from Medical Examiner Hydrogen Cyanide Totally encapsulated chemical protective (TECP) clothing with self contained breathing apparatus is recommended Cutaneous absorption must be avoided Readily absorbed through intact skin May cause systemic poisoning with little or no skin irritation 14
Patient Decontamination NASSAU COUNTY FIRE COMMISSION HAZARDOUS MATERIALS COMMITTEE REMSCO ADVISORY For More Information Drew Fried drew.fried@gmail.com www.colofirechiefs.org www.hazmatfc.com 15
QUESTIONS? 16